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Child Health > Urology > Flashcards

Urology Flashcards

1
Q

Causes of scrotal swelling

A 
Painless:
Hernia
Hydrocele
Varicocele 
Idiopathic scrotal oedema
Testicular tumours (rare)
Painful:
Testicular torsion
Torsion of testicular appendage
Epididymitis
Orchitis 
Zipper entrapment
Henoch-Schonlein purpura
Allergic reactions
Insect bites 
Injuries
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2
Q

Inguinal hernia

A

Cannot get above it on examination
Cough impulse may be present
May be reducible

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3
Q

Testicular tumours

A 
Discrete testicular nodule 
May have associated hydrocele
Symptoms of metastatic disease
USS scrotum 
AFP and B-HCG
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4
Q

Acute epididymo-orchitis

A

History of dysuria and urethral discharge
Swelling may be tender and eased by elevated testis
Most cases due to Chlamydia

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5
Q

Epididymal cysts

A

Single or multiple cysts
May contain clear or opalescent fluid (spermatocele)
Usually occur over 40 years of age
Painless
Lie above and behind testis
Usually possible to get above lump on examination

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6
Q

Hydrocele (communicating)

A 
Non-painful, soft fluctuant swelling 
Get above it on examination
Clear fluid
Transilluminate
Feature of testicular cancer
Due to patent processus vaginalis
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7
Q

Testicular torsion

A

Severe, sudden onset testicular pain
Risk factors: abnormal testicular lie
Typically affects adolescents and young males
Testes tender and pain not eased by elevation
Urgent surgery indicated, contra-lateral testis should also be fixed

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8
Q

Varicocele

A

Varicosities of pampiniform plexus
Typically occur on left (testicular vein drains into renal vein)
Presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicocele may affect fertility

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9
Q

Management of testicular malignancy

A

Orchidectomy via inguinal approach
Allows high ligation of testicular vessels
Avoids exposure of another lymphatic field to tumour

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10
Q

Management of testicular torsion

A

Commonest in young teenagers
Intermittent torsion
Prompt surgical exploration and testicular fixation
Sutures or by placement of testis in a Dartos pouch

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11
Q

Management of varicoceles

A

Managed conservatively

If concerns about fertility: surgery/ radiology

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12
Q

Management of epididymal cysts

A

Excised using a scrotal approach

Sclerotherapy

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13
Q

Management of hydrocele

A

Ligate processus

Inguinal approach

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14
Q

Conditions associated with epididymal cysts

A

Polycystic kidney disease
CF
VHL syndrome

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15
Q

Hydroceles may develop secondary to:

A

Epididymo-orchitis
Testicular torsion
Testicular tumours

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16
Q

Acute scrotal disorders in children

A

Testicular torsion: most common around puberty
Irreducible inguinal hernia: most common in children <2 years old
Epididymitis: rare in prepubescent children

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17
Q

Enuresis

A

Involuntary urination

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18
Q

Nocturnal enuresis

A

Bed wetting

Up to 3/4 years

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19
Q

Diurnal enuresis

A

Inability to control bladder function during the day

Up to 2 years

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20
Q

Primary nocturnal enuresis causes

A

Variation on normal development (most common)
FH
Overactive bladder
Fluid intake
Failure to wake
Psychological distress
Chronic constipation, UTI, learning disability, cerebral palsy

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21
Q

Overactive bladder pathophysiology

A

Frequent small volume urination prevents development of bladder capacity
Primary nocturnal enuresis

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22
Q

Management of primary nocturnal enuresis

A

2 week diary: toileting, fluid intake, bed wetting episodes
History and examination
Reassure if <5
Lifestyle changes: reduce fluid, easy toilet access, pass urine before bed
Encouragement and positive reinforcement
Treat any underlying cause or exacerbating factors, e.g. constipation
Enuresis alarms
Pharmacological treatment

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23
Q

Secondary nocturnal enuresis

A

Dry for 6 months

Then start bedwetting

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24
Q

Causes of secondary nocturnal enuresis

A 
UTI
Constipation
TY1 diabetes
Maltreatment
New psychosocial problems
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25
Q

Diurnal enuresis

A

Stress incontinence
Urge incontinence
Dry at night
More frequent in girls

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26
Q

Urge incontinence

A

Overactive bladder

Little warning before emptying

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27
Q

Stress incontinence

A

Leakage of urine during physical exertion, coughing or laughing

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28
Q

Causes of diurnal enuresis

A 
Recurrent UTI
Psychosocial problems
Constipation 
Urge incontinence
Stress incontincne
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29
Q

Enuresis alarms

A

Device that makes a noise at first sign of bed wetting
Wakes child and stops them from urinating
High level of training and commitment
Needs to be used consistently for >3 months

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30
Q

Medication for nocturnal enuresis

A

Desmopressin: ADH analogue, reduces volume of urine produced by kidneys, taken at bedtime with intention of reducing nocturnal enuresis

Oxybutynin: anticholinergic, reduces contractility of bladder

Imipramine: TCA, relaxes bladder and allows sleep

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31
Q

Cryptorchidism

A

Congenital absence of one or both testes in the scrotum due to a failure of the testes to descend during development

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32
Q

Epidemiology of cryptorchidism

A

6% newborns

1.5-3.5% at 3 months

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33
Q

Types of cryptorchidism

A

True undescended testis: absent from scrotum but lies along the line of testicular descent

Ectopic testis: testis found away from normal path of descent

Ascending testis: secondary ascent out of scrotum

Bilateral: exclude hormonal causes, androgen insensitivity syndrome, disorder of sex development

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34
Q

Pathophysiology of Cryptorchidism

A

Testis descends from abdomen to scrotum

Pulled by gubernaculum within processus vaginalis

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35
Q

Risk factors for cryptorchidism

A

Prematurity
Low birth weight
Having other abnormalities of genitalia (hypospadias)
First degree relative with cryptorchidism

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36
Q

Cryptorchidism history

A

Clarify if testis has even been seen or palpated within scrotum
Newborn check
Parents noticed testicle in scrotum in certain situations (warm bath)

37
Q

Cryptorchidism examination

A

Retractile/ normal descended testis
Proceed to palpation to locate testis
Infant/ child laid flat on bed
Palpate along inguinal canal
See if testis can be gently milked down to the base of the scrotum (retractile testis)
If it is pulled down but under tension in the base: high testes
Inguinal undescended testes

38
Q

Impalpable undescended testes

A

Ectopic
Intra-abdominal
Absent
Impalpably small

39
Q

Differential diagnosis undescended testes

A 
Normal retractile testis
True undescended testis 
Ectopic testis 
Absent testis
Bilateral impalpable testis: disordered sexual development, endocrine
40
Q

Cryptorchidism urgent referral to senior paediatrician within 24hrs

A

Disordered sexual development
Ambiguous genitalia
Hypospadias
Bilaterally undescended

Access to endocrinology and urology services

41
Q

Presentation of congenital adrenal hyperplasia and cryptorchidism
Initial management

A

Risk of salt-losing crisis
Need high-dose NaCl therapy
Careful glucose monitoring
Steroid replacement

42
Q

Role of imaging in cryptorchidism

A

No benefit

USS/MRI poor sensitivity

43
Q

Management of cryptorchidism
At birth
6-8 weeks:
3 months:

A

Birth: review at 6-8weeks
6-8 weeks: if fully descended no further action, if unilateral re-examine at 3 months
3 months: follow-up if retractile, refer to surgery/urology for definitive intervention if undescended

Examination under anaesthesia, then laparoscopy to locate an impalpable testis

44
Q

Management cryptorchidism

Palpable testes

A 
Open orchidopexy 
If 6-12months of age
Via groin incision 
Processus vaginalis and cremasteric covering is separated from cord
Testis mobilised and fixed in scrotum
45
Q

Management of cryptorchidism

Intra-abdominal testes

A

Single stage or Fowler-Stephens procedure (2 stage procedure)
Testicular vessels ligated, for collateral to come in
Bring testes into scrotum 6 months later

46
Q

Management of cryptorchidism

Atrophic testis

A

Remove a trophic testis

Groin exploration if vas/testicular vessels blind-ending or entering deep inguinal ring

47
Q

Retractile testes

A

Scrotum-> inguinal canal
Cold or cremasteric reflex
Normal variant
Orchidopexy if fully retract or fail to descend

48
Q

Surgical complications of undescended testes

A

Short-term:
Infection
Bleeding
Wound dehiscence

Long-term:
Testicular atrophy
Testicular re-ascent

49
Q

Complications of an undescended testis

A

Impaired fertility: too warm
Testicular cancer
Torsion

50
Q

Testicular torsion

A 
Spermatic cord and its contents twists within tunica vaginalis 
Compromising blood supply to testicle 
Surgical emergency 
12-25 years old and neonates 
Will infarct within hours
51
Q

Pathophysiology of testicular torsion

A 
Mobile testis rotates on the spermatic cord
Reduced arterial blood flow 
Impaired venous return 
Venous congestion 
Resultant oedema
Infarction to testis if not corrected

Bell-clapper deformity more prone to developing testicular torsion

52
Q

Bell clapper deformity

A

Horizontal lie to testes
More prone to developing testicular torsion
Testis lacks normal attachment to tunica vaginalis
More mobile, increasing likelihood of it twisting on cord structures

53
Q

Neonatal testicular torsion

A

Attachment between scrotum and tunica vaginalis not full formed
Entire testis and tunica vaginalis can tort
Extra-vaginal torsion
Can occur in-utero

54
Q

Risk factors for testicular torsion

A

12-25 age
Previous torsion
FH
Undescended testes

55
Q

Clinical features of testicular torsion

A

Sudden onset severe unilateral testicular pain
Associated with nausea and vomiting, secondary to the pain
Referred abdominal pain
High position with horizontal lie
Swollen and tender
Cremasteric reflex absent
Pain continues despite elevation (negative Prehn’s sign)

56
Q

DD of testicular torsion

A 
Epididymo-orchitis 
Trauma
Inguinal hernia
Testicular cancer
Renal colic
Hydrocele
Idiopathic scrotal oedema
Torsion of the hydatid of Morgagni
57
Q

Torsion of the Hydratid of Morgagni

A

R4emnant of Müllerian duct
Common testicular appendage
Common in younger age group
Scrotum usually less erythematous with a normal lie of the testis
Blue dot may be present in the upper half of the hemi scrotum
Visible infarcted hydatid

58
Q

Investigations of testicular torsion

A

Clinical diagnosis
Straight to theatre for scrotal exploration
Doppler US: investigate potential compromised blood flow to testis
Urine dipstick

59
Q

Management of testicular torsion

A

Surgical emergency
4-6hr window to salvage testes
Urgent surgical exploration
Strong analgesia and anti-emetics, NBM, IV fluids

Fix both testes to scrotum
Bilateral orchidopexy

If non-viable: orchidectomy and prosthesis can be inserted

60
Q

Complications of testicular torsion

A

Testicular infarction
Atrophy of affected testicle

After scrotal exploration:
Chronic pain
Palpable suture 
Risk to future fertility
Theoretical risk of future torsion despite fixation
61
Q

Epididymitis

A

Inflammation of epididymis

15-30 and >60years

62
Q

Pathophysiology of epididymo-orchitis

A

Local extension of infection
From LUT: bladder and urethra
Via enteric: classic UTI
Or non-enteric: STI

63
Q

Epididymo-orchitis in <35 organisms

A

Sexual transmission
N.gonorrhoea
C.trachomatis

64
Q

Epididymo-orchitis in >35 organisms

A 
Enteric organism from a urinary tract infection 
E.coli
Proteus spp
Klebsiella pneumonia
Pseudomonas aeruginosa

Bladder outflow obstruction from prostatic enlargement
Retrograde ascent of pathogen

65
Q

Mumps orchitis

A

Post-pubertal boys after mumps viral infection
Unilateral or bilateral orchitis
Accompanied with a fever, around 4-8 days after onset of mumps parotitis
Disease self-resolves within a week with supportive management

66
Q

Complications of mumps orchitis

A

Testicular atrophy

Infertility

67
Q

Management of mumps orchitis

A

Mumps IgM/IgG serology
Notifiable disease
Inform local health protection team if suspicion

68
Q

Risk factors for epididymo-orchitis

A

Depends on mechanism of disease: STI/UTI
Non-enteric causes: MSM, multiple sexual partners, known contact of gonorrhea
Enteric causes: recent instrumentation or catheterisation, BOO, immunocompromised state

69
Q

Clinical features of epididymo-orchitis

A

Unilateral scrotal pain and swelling
Fever and rigors

Dysuria, storage LUTS, urethral discharge

Red and swollen
Tender on palpation
Associated hydrocele

Prehn’s sign positive

70
Q

DD of epididymo-orchitis

A 
Testicular torsion
Testicular trauma
Testicular abscess
Epididymal cyst
Hydrocele
Testicular tumour
71
Q

Epididymo-orchitis investigations

A 
Urine dipstick 
Mc&S
Collect first-void urine 
Send urine for NAAT: N.gonorrhoeae, C.trachomatis, M.genitalium
STI screen
FBC, CRP
Bloo cultures 
USS Doppler for testicular blood flow
72
Q

Initial management of epididymitis

A 
Outpatient
Ax
Analgesia
Enteric: ofloxacin 
STI: ceftriaxone and doxycycline
73
Q

Complications of epididymitis

A

Reactive hydrocele
Abscess
Testicular infarction

74
Q

Hypospadias

A

Urethral meatus located at abnormal site

Usually on underside of the penis

75
Q

Pathophysiology of hypospadias

A

Arrest of penile development

Hypoplasia of ventral tissue of the penis

76
Q

Clinical features of hypospadias

A

Abnormal urinary flow
Abnormal penile curvature during erections

Ventral opening of urethral meatus
Ventral curvature of penis or ‘Chordee’
Dorsal hooded foreskin

77
Q

Classification of hypospadias

A 
Glandular 
Coronal 
Shaft 
Scrotal
Perineal
78
Q

Differential diagnosis of hypospadias

A

Disorders of sexual development

Congenital adrenal hyperplasia

79
Q

Investigations to rule out DSD

Disorder of sex development

A 
Detailed history and examination
Karyotype
Pelvis US scan 
Urea and electrolytes
Endocrine hormones: testosterone, 17 alpha-hydroxyprogesterone
LH
FSH
ACTH
Renin 
Aldosterone
80
Q

Management of hypospadias

A

Urethroplasty with graft from foreskin (advise against circumcision)

81
Q

Aims of urethroplasty in hypospadias

A

Bringing the meatus to the glans of the penis
Chordee is corrected to straighten the penis
Dorsal foreskin is managed with either circumcision or reconstruction, depending on anatomy, parental and surgical preference

82
Q

Short term complications of hypospadias

A

Post surgical catheter may block, become displaced or kinked
Urethral catheter may cause pain and bladder spasms (Give oxybutynin)
Bleeding
Infection

83
Q

Long term complications of hypospadias

A

Urethral fistula

Risks of mental or urethral stenosis

84
Q

Complications of untreated BXO

A

Meatal stenosis
Phimosis
Erosions of glans and prepuce which can extend to urethra

85
Q

Surgical complications of BXO

A

Swelling
Serous discharg around penis for a week
Infection

86
Q

Management of BXO

A

Circumcision

Send foreskin off to histopathology

87
Q

Balanitis xerotica obliterans

A

Keratinisation of tip of foreskin causes scarring

Prepuce remains non-retractile

88
Q

Clinical features of BXO

A 
Ballooning of foreskin during micturition 
Self-resolving as prepuce becomes more mobile with age, normal age 2-4
Scarring of urethral meatus
Irritation
Dysuria
Haematuria
Local infecton
Urinary obstruction
89
Q

Examination of BXO

A

White, fibrotic and scarred prep UTi all tip

Difficult to visualise meatus

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